Membership Form

 Click here to download the Membership Form 2018-2019

Alternatively fill out and submit this online form:

Please check the appropriate box (required).
Are you: a person with aphasiaa caregivera friend of a person with aphasia

The following questions relate to people with aphasia only:

Do you have any medical conditions, e.g. heart problems, epilepsy, hearing loss, etc or special
If yes, please

Date(s) of your

If your aphasia is not a result of a stroke, please indicate cause of the aphasia:

Please try to tell us about your aphasia:

Your ability to express yourself verbally:

Your understanding of what others are saying:

Your understanding of what you read:

Your ability to express yourself in writing:

Membership costs $15 annually for an individual, or $20 for (2) people from the
same family.
Payment options:
Cheque/cash/online banking 060 383 0179748 00 or Post to PO Box 736 Orewa

Membership Renewal Form

 Click here to download the Membership Renewal Form 2018-2019